201109462 - Laserfiche WebLink

Browse

LIFE INSURANCE VERIFICATION 201109462 � �� THIS�SECTfON TO BE�COIvIl'L�TED BY�NANT AND EXECUTED BY MANAGEMENT ;��,,,;; TO: Name&Address Phone Number Fax Number RE: App]icandTenant Name Social Security Number Unit#(if assigned) I hereby authorize release of my]ife insurance information. Signature of Applicant/Tenant Date The individual(s)named directly above is an applicanUtenant of a housing program that requires�erification of income.The information provided will remain confidential and will be used solely for the purpose oi determining eligibility for occupancy.Your prompt response is crucial and greatly appreciated. Signature of Owner's Representative Return Form To: � `;� ::>TH[S�Ti0^I TO B�(.-Uh%IFLBTELi°BY LiFE TI�SUICe3idCE PI20VIDFR�a �� ;' � ��, ,� �� Dividend Paid and/or Interest Rate (this includes reinvested interest/dividends) Policy Account# Cash Surrender Value ("N/A"if no interest or dividend paid) $ $ / % $ $ � % $ $ � % Does the applicant/tenant have access to the lump sum amount? ❑Yes ❑No Is the applicanUtenant receiving periodic payments ❑Yes ❑No If yes,what amount $ Frequency Additional Remarks: (please indicate any anticipated changes.) Signature Printed Name&Title Date Name and A ress P one# Fax# E-ma� NOTE: Section 1001 of Title 18 of the U.S.Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. (Updated 12/10)